Introduction Health insurance coverage is a critical determinant of cancer care access. However, the association of different insurance statuses affecting survival outcomes remains understudied worldwide. This meta-analysis provides global evidence on the association between insurance status and survival and highlights structural health inequities across national health insurance systems. Methods We searched five databases for cohort studies published between 1 January 2000 and 15 July 2025. Random-effect multilevel and traditional meta-analyses were employed to address heterogeneity. The Newcastle-Ottawa Scale (NOS) and the ROBINS-I method assessed all studies for quality. Results We included 37 studies between 2000 and 2025, contributing 219 effect sizes. In the United States (US), patients insured in Medicare (HR: 1.29, 95% CI: 1.17–1.42, P < 0.001; τ2(2) = 0.046, I2(2) = 67.28%; τ2(3) = 0.022, I2(3) = 31.89%), Medicaid (HR: 1.39; 95% CI: 1.28–1.51, P < 0.001; τ2(2) = 0.049, I2(2) = 74.07%; τ2(3) = 0.016, I2(3) = 24.60%), or without insurance (HR: 1.42, 95% CI: 1.31–1.53, P = 0.001; τ2(2) = 0.032, I2(2) = 65.99%; τ2(3) = 0.015, I2(3) = 30.77%) had worse overall survival (OS) than private insurers. Cancer stage, cancer type, and the adjustment variables are moderators of effect size heterogeneity in the US. The association between insurance status and survival was stronger in early-stage (I-II) cancers and among patients with breast and prostate cancer, whereas survival disparity across insurance statuses was smaller or not statistically significant for advanced (III-IV) stages and patients diagnosed with lung, liver, and colorectal cancer. In China, patients without Urban Employee Basic Medical Insurance (non-UEBMI) showed worse OS (HR: 1.39; 95% CI: 1.22–1.59; I2 = 60.0%; τ2 = 0.012) than UEBMI patients. Qualitative evidence from Germany, South Korea, Thailand, and Brazil did not identify statistically significant associations between insurance status and cancer survival outcomes. Uninsured individuals were experiencing poorer OS than those with any other form of insurance status globally. Conclusions The association between insurance status and cancer survival differs across national health insurance systems. Insurance policies should prioritize early-stage cancer care, cancer types with a favorable prognosis, and uninsured groups. Future research should use prospective international cohorts to explore how insurance structures and covariate interactions affect survival and to achieve equity in global cancer care.

Association of insurance status among cancer patients and survival outcomes: a systematic review and meta-analysis

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2025年10月10日

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Jiashuai Tian,
Jiayang Kong,
Na Zhou,
Liliang Zhang,
Xinyu Cai,
Dai Su,
Guangying Gao

摘要

Introduction

Health insurance coverage is a critical determinant of cancer care access. However, the association of different insurance statuses affecting survival outcomes remains understudied worldwide. This meta-analysis provides global evidence on the association between insurance status and survival and highlights structural health inequities across national health insurance systems.

Methods

We searched five databases for cohort studies published between 1 January 2000 and 15 July 2025. Random-effect multilevel and traditional meta-analyses were employed to address heterogeneity. The Newcastle-Ottawa Scale (NOS) and the ROBINS-I method assessed all studies for quality.

Results

We included 37 studies between 2000 and 2025, contributing 219 effect sizes. In the United States (US), patients insured in Medicare (HR: 1.29, 95% CI: 1.17–1.42, P < 0.001; τ²₍₂₎ = 0.046, I²₍₂₎ = 67.28%; τ²₍₃₎ = 0.022, I²₍₃₎ = 31.89%), Medicaid (HR: 1.39; 95% CI: 1.28–1.51, P < 0.001; τ²₍₂₎ = 0.049, I²₍₂₎ = 74.07%; τ²₍₃₎ = 0.016, I²₍₃₎ = 24.60%), or without insurance (HR: 1.42, 95% CI: 1.31–1.53, P = 0.001; τ²₍₂₎ = 0.032, I²₍₂₎ = 65.99%; τ²₍₃₎ = 0.015, I²₍₃₎ = 30.77%) had worse overall survival (OS) than private insurers. Cancer stage, cancer type, and the adjustment variables are moderators of effect size heterogeneity in the US. The association between insurance status and survival was stronger in early-stage (I-II) cancers and among patients with breast and prostate cancer, whereas survival disparity across insurance statuses was smaller or not statistically significant for advanced (III-IV) stages and patients diagnosed with lung, liver, and colorectal cancer. In China, patients without Urban Employee Basic Medical Insurance (non-UEBMI) showed worse OS (HR: 1.39; 95% CI: 1.22–1.59; I² = 60.0%; τ² = 0.012) than UEBMI patients. Qualitative evidence from Germany, South Korea, Thailand, and Brazil did not identify statistically significant associations between insurance status and cancer survival outcomes. Uninsured individuals were experiencing poorer OS than those with any other form of insurance status globally.

Conclusions

The association between insurance status and cancer survival differs across national health insurance systems. Insurance policies should prioritize early-stage cancer care, cancer types with a favorable prognosis, and uninsured groups. Future research should use prospective international cohorts to explore how insurance structures and covariate interactions affect survival and to achieve equity in global cancer care.